Download LMC Patient Packet

1446 Lee Beard Way
Augusta, GA 30901
706-828-7468
706-724-7566 (Fax)
www.bgcrcenter.org
Dr. Sam Davis, CEO
Jean Callaway, Executive Director
Dr. Willie J. Hillson, Physician
Dr. Benjamin Rucker, Medical Director
Dear Patient,
We would like to take this opportunity to welcome you to our Medical Center. We want to assure you that
we will do everything possible to make your visit a pleasant one. To accomplish this, we need your help.

Complete the Patient Registration Form.

Sign the Medical Records Release Form.

Bring your picture ID and health insurance card with you to each visit.

Pay the co-payment and patient balance at each visit.

Bring ALL medications with you to each visit.

Please call if you are going to be over 30 minutes late.

Please allow 24 hours for all prescription refills.

Please call 24 hours in advance for cancellation.
Our doctors care for many patients and occasionally run late due to unexpected problems that you or
other patients may have, so please be understanding when this occurs. You may want to bring reading
material to occupy your time in the event your appointment is delayed. All of our patients have many
questions and our staff tries to give every patient the time needed to address their concerns. We
appreciate your patience during these busy times.
Again, welcome to Lamar Medical Center. If you have any questions or concerns, please call 706-8287468.
Respectfully,
Lamar Medical Center Staff
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1446 Lee Beard Way
Augusta, GA 30901
706-828-7468
706-724-7566 (Fax)
Dr. Sam Davis, CEO
Jean Callaway, Executive Director
Dr. Benjamin Rucker, Medical Director
PATIENT REGISTRATION
Patient Name:___________________________________________________
Address: _________________________________________________________
City:_______________ State:_____________ Zip Code____________
Phone #:____________ Home:_________________
Cell:_________________
SS#: ________________ DOB:______________ GENDER: Female______ Male________
Relationship Status: Married____ Single____ Widowed____ Separated____ Divorced____
Race (OPTIONAL): Black_____ White _____ Hispanic _______ Other ______
Emergency Contact: _______________ Phone#: ___________ Relationship __________
Employment: ____________________________________ Phone #:____________________
Address: ________________________________________________________________________
City: _________________________ State: _____________________ Zip Code: ______________
Primary Ins: _________________________________ Phone #:______________________________
Policy #: ____________________________ Group ID# ____________________________
Claim Address: ____________________________________________________________
City: ___________________ State: _____________________ Zip Code: ______________
Secondary Ins: __________________ Phone # : _______________________
Policy #: _______________________ Group ID #: ____________________________
Claim Address: __________________________________________________________
City: __________________ State: _____________________ Zip Code: ______________
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1446 Lee Beard Way
Augusta, GA 30901
706-828-7468
706-724-7566 (Fax)
www.bgcrcenter.org
Dr. Sam Davis, CEO
Jean Callaway, Executive Director
Dr. Benjamin Rucker, Medical Director
MEDICAL RELEASE
FROM PRIOR HEALTHCARE PROVIDER
I AUTHORIZE ___________________________________________________________
TO RELEASE MEDICAL INFORMATION ON ME TO LAMAR MEDICAL CENTER.
I HEREBY RELEASE LAMAR MEDICAL CENTER FROM ALL LEGAL RESPONSIBILITIES OR
LIABILITIES THAT MAY ARISE FROM THE ACT I HAVE AUTHORIZED ABOVE.
PATIENT’S NAME:_______________________________________________________
ADDRESS: _____________________________________________________________
BIRTHDATE: ___________________________________________________________
___________________________
SIGNED
___________________________
WITNESS
___________________________
DATE
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1446 Lee Beard Way
Augusta, GA 30901
706-828-7468
706-724-7566 (Fax)
www.bgcrcenter.org
Dr. Sam Davis, CEO
Jean Callaway, Executive Director
Dr. Benjamin Rucker, Medical Director
Consent to the Use and Disclosure of Health Information, Payment or Healthcare Operations
I understand that as part of my healthcare, this organization originates and maintains health records
describing my health history, symptoms, examinations and test results, diagnoses, treatment and any
plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment.

A means of communication among the many health professionals who contribute to my care

A source of information for applying my diagnosis and surgical information to my bill

A means by which a third-party payer can verify that services billed were actually provided.

A tool for routine healthcare operations such as assessing quality and reviewing the competence
of healthcare professionals.
I understand and have been provided with a Notice of Information Practices that provides a more
complete description of information uses and disclosures. I understand that I have the right to review the
notice prior to signing this consent. I understand that the organization reserves the right to change their
notice and practices and prior to implementation will mail a copy of any revised notices to the address I’ve
provided. I understand that I have the right to object to the use of my health information for directory
purposes. I understand that I have the right to request restrictions as to how my health information may
be uses or disclosed to carry out treatment, payment, or healthcare operations and that the organization
is not required to agree to the restrictions requested. I understand that I may revoke this consent in
writing, except to the extent that the organization has already taken action in reliance thereon.
I request the following restrictions to the use or disclosure of my health information:
Patient/Legal Guardian Signature: _____________________________________________________
Date: ____________________________________________________________________________
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1446 Lee Beard Way
Augusta, GA 30901
706-828-7468
706-724-7566 (Fax)
www.bgcrcenter.org
Dr. Sam Davis, CEO
Jean Callaway, Executive Director
Dr. Benjamin Rucker, Medical Director
PRESENT ILLNESS
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
PAST SURGICAL HISTORY
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
MEDICATIONS (List Prescription and Over the Counter)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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MEDICAL HISTORY (Check all that apply to you)
High Blood Pressure
Low Blood Pressure
Chest Pain
Heart Attack
Diabetes
Renal (Kidney Disease)
CVA (Stroke)
Thyroid Disease
Palpitations
Syncope (Passing Out)
Shortness of Breath
Asthma
COPD
Emphysema
Ulcers
Liver Disease
Seizures
Vertigo (Dizziness)
Post Menopausal
Arthritis
Gout
Stomach Problems
Cancer(s)
*Specify Below*
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
FAMILY HISTORY:
Mother:_____________________________________________________________________________
Father:______________________________________________________________________________
Sister(s):____________________________________________________________________________
Brother(s):__________________________________________________________________________
PERSONAL DATA:
Occupation:_________________________________________________________________________
Smoking:
NO_____ YES_______
Packs per day ____________ # of years___________
Alcohol
Intake__________________________________________________________________________
Diet:________________________________________________________________________________
Pyschological
Problems:__________________________________________________________________
Children:
(ages/sex)___________________________________________________________________________
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